ON THE SPOT

he origins of birthmarks

BROBSON LUTz M.D.

What do the Russians and the New Orleans Saints have in common? Both the last Russian head of state and the current Super Bowl-winning quarterback have noticeable birthmarks. Mikhail Gorbachev has a port wine spot; Drew Brees was born with a large mole on his face.

As the name implies, most birthmarks are apparent at birth but some become visible in the days to weeks after birth.

Birthmarks come in all shapes and sizes: Some are dubbed beauty spots; some are associated with other medical problems; some cause psychological trauma while some bearers go on to lead countries and winning football teams.

Vascular birthmarks are due to localized abnormalities in blood vessel formations, while moles or nevi at birth are related to an excessive concentration of pigment producing cells. Most birthmarks are small, but larger ones aren’t uncommon. Some are simply flat skin discolorations; others rise above the skin’s surface and can be bumpy. Reds, browns and blues are the predominant colors.

The most common birthmark is the stork bite or a salmon patch. They are pink, flat marks usually located on the head or back of the neck. About half of all newborns are born with these marks caused by stretching of underlying blood vessels that can change color with sudden room temperature variants and with crying. An experienced pediatrician or nurse can diagnose these on sight. Treatment is rarely required. Most disappear by the time the baby is crawling, except for those on the back of the neck, which can linger.

The second most common birthmark is the congenital melanocytic nevi or mole. A melanocytic nevus is a collected cluster of brown to almost black skin pigment cells all hanging out together, instead of being evenly distributed across the skin surface. But most small moles aren’t true birthmarks, as they show up during childhood and the average adult can have 40 or more.

According to local pediatrician Dr. Keith Perrin, about one out of 10 newborns has at least one visible mole at birth.

These congenital melanocytic nevi range in size from mostly pinpoint to an occasional huge one. The Nelson Textbook of Pediatrics states about one baby in 20,000 is born with an especially large mole, a lesion termed giant congenital pigmented nevi. Any large collection of pigmented cells deserves close observation as over time a few transform into malignant melanoma.

This brings us to Drew Brees. A sportswriter in 1999 described Brees’ birthmark as brown and fuzzy approximating the “size, shape and texture of a small woolly-bear caterpillar.” In a January 2005 New York Times article, sportswriter Lee Jenkins wrote than an occasional girl dancing with Brees would confuse his right upper cheek birthmark on for a patch of dirt, lick her finger, and try to wipe it off:

“The hairy birthmark has become a symbol of Brees’ imperfections, which are noticeable but somehow charming.

When Brees was 3, his parents considered having the birthmark removed, but doctors said that there was no harm in keeping it and suggested that the boy had been kissed by an angel. When he was in college and made the Playboy All-American team, the magazine airbrushed the birthmark from a photo that it ran. Looking back, it was like airbrushing Cindy Crawford’s mole.

“Brees had one game at Purdue in which he completed 55 passes in 83 attempts, another in which he threw for 522 yards. A teammate wore Brees’ jersey to a Halloween party and applied a black mark to his cheek. The costume quickly became part of the fall wardrobe in West Lafayette, Ind. The stands would be filled with followers who smeared mud or mascara or some other substance on their faces.”

More recently the birthmark on Drew Brees’ face has had a reddish tinge. Brees showed up on the “Oprah” show a few days after the Super Bowl. Oprah started the interview with “Who just kissed you?” and made an awkward move to wipe off the supposed smudge before she realized her goof.

Another sports figure with a birthmark was baseball player Matt Luke, who played with several major league teams in the 1990s. He was born with a congenital melanocytic nevus that about covered much of his face. The large size of this birthmark caused his physicians to recommend surgical removal. He underwent multiple plastic surgeries beginning about age 5. Classmates taunted him with names like scar face, dirty face and charcoal face, according to the Web site www.CosmeticSurgery.com. After one major surgery, he was advised to refrain from all sports for at least three months to prevent extensive scar formation; he chose sports over scars, and his scars became part of baseball and plastic surgery lore.

Gorbachev has a classic port wine birthmark, though it really looks more like a Pinot Noir. Large port wine birthmarks are caused by a defective nerve supply to the small veins in the skin and occur in about three births per 1,000. The veins in the involved area dilate but cannot contract normally, allowing blood to pool near the surface of the skin and resulting in color changes ranging from pale pink or red to dark purple. They stay the same size throughout life but can thicken with age.

Hemangiomas are another common vascular birthmark apparent at birth or shortly thereafter. They are more common in female infants and premature babies of both sexes. A strawberry mark is a red-colored complex of abnormal blood vessels that increases in size during the baby’s first year. They range in size from barely visible to large and disfiguring. Most stop growing by 18 months or so, and slowly regress over the next 10-plus years.

Other vascular malformations present at birth remain unnoticed until they “pop out” later in life. High-pressure arterial blood usually flows through smaller and smaller arteries that finally merge into low-pressure microscopic capillaries;

in turn they empty into larger and larger low-pressure veins that return oxygen depleted blood to the heart and lungs for recycling. An abnormal shunt between the arterial and venous blood vessels is called an arteriovenous malformation. Over time these vessels thicken and become more and more obvious. These birthmarks turn into firm masses and are most common on the lips and other head and neck locations.

While most birthmarks are simply superficial blemishes, some can be harbingers of underlying medical problems.

Café au lait spots are flat, oval discolorations with smooth borders resembling the color of coffee with milk made famous by Morning Call and Café Du Monde. Most persons with a few small café au lait spots have nothing to worry about, but more than five of these spots or a very large one can be a clue to underlying neurofibromatosis, a rare genetic disorder with a wide spectrum of minor to major skin and internal derangements.

Parents of children with birthmarks need to be assured that the birthmark wasn’t of their doing – an unmet craving for strawberries during pregnancy didn’t cause a strawberry birthmark. Most of the time the problem is only cosmetic, but rare, specific birthmarks are associated with underlying potentially serious medical problems.

Most birthmarks are temporary and need no treatment. Some vascular birthmarks are treated with steroid injections to slow down their growth. A special laser treatment early on is often recommended for large facial port wine stains on the face in an effort to prevent psychological and social problems. Covermark and other concealing cosmetics might help hide permanent birthmarks. Larger or disfiguring marks with a potential to cause psychological distress deserve specialty consultation.

Along at least one Uptown parade route this past Mardi Gras, birthmark tattoos were all the rage. “A vendor was selling temporary tattoos that looked just like Drew Brees’ birthmark,” WWL medical reporter Meg Farris says. “He bought them for a quarter a piece and hawked them along the parade route for two bucks each.”